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Background: The association of working from home (WFH) with physical activity (PA) and sedentary behavior (SB) has been explored; however, this association during periods without stringent measures to combat coronavirus disease 2019 is undercharacterized. Particularly, few studies have evaluated the potential effect modification on its associations. Therefore, this study aimed to investigate the associations of WFH frequency with accelerometer-measured PA and SB, along with its effect modifiers, among Japanese white-collar workers during the later pandemic period. Methods: A cross-sectional study involving 1133 white-collar workers residing in the Tokyo metropolitan area was conducted between April 2022 and March 2023. WFH frequency was evaluated through a self-report questionnaire, while SB and PA during weekdays were measured using a triaxial accelerometer. Linear regression models adjusting for potential confounders were used to examine the association of WFH frequency with PA and SB. Results: Regardless of activity intensity, individuals who worked at home, even for 1 to 2 days per week, demonstrated lower levels of PA and higher levels of SB as compared with those who did not (P <.05). For example, difference between never and ≥5 days per week WFH was approximately 70 minutes/day for total PA and about 4000 steps/day for step counts. Associations between WFH and decreased PA were more pronounced in workers who were older, female, less educated, in sales and service work, nonregular staff, and precontemplating changes in exercise and eating habits. Conclusions: We report that WFH was associated with decreased PA and increased SB in Japanese white-collar workers with pronounced associated in several subgroups. [ABSTRACT FROM AUTHOR]

BACKGROUND: Numerous studies have linked fine particulate matter (PM2.5) to increased cardiovascular mortality. Less is known how the PM2.5-cardiovascular mortality association varies by use of cardiovascular medications. This study sought to quantify effect modification by statin use status on the associations between long-term exposure to PM2.5 and mortality from any cardiovascular cause, coronary heart disease (CHD), and stroke. METHODS: In this nested case-control study, we followed 1.2 million community-dwelling adults aged ≥66 years who lived in Ontario, Canada from 2000 through 2018. Cases were patients who died from the three causes. Each case was individually matched to up to 30 randomly selected controls using incidence density sampling. Conditional logistic regression models were used to estimate odds ratios (ORs) for the associations between PM2.5 and mortality. We evaluated the presence of effect modification considering both multiplicative (ratio of ORs) and additive scales (the relative excess risk due to interaction, RERI). RESULTS: Exposure to PM2.5 increased the risks for cardiovascular, CHD, and stroke mortality. For all three causes of death, compared with statin users, stronger PM2.5-mortality associations were observed among non-users [e.g. for cardiovascular mortality corresponding to each interquartile range increase in PM2.5, OR = 1.042 (95% CI, 1.032-1.053) vs OR = 1.009 (95% CI, 0.996-1.022) in users, ratio of ORs = 1.033 (95% CI, 1.019-1.047), RERI = 0.039 (95% CI, 0.025-0.050)]. Among users, partially adherent users exhibited a higher risk of PM2.5-associated mortality than fully adherent users. CONCLUSIONS: The associations of chronic exposure to PM2.5 with cardiovascular and CHD mortality were stronger among statin non-users compared to users.

INTRODUCTION: The LIfestyle for BRAin Health (LIBRA) index yields a dementia risk score based on modifiable lifestyle factors and is validated in Western samples. We investigated whether the association between LIBRA scores and incident dementia is moderated by geographical location or sociodemographic characteristics. METHODS: We combined data from 21 prospective cohorts across six continents (N = 31,680) and conducted cohort-specific Cox proportional hazard regression analyses in a two-step individual participant data meta-analysis. RESULTS: A one-standard-deviation increase in LIBRA score was associated with a 21% higher risk for dementia. The association was stronger for Asian cohorts compared to European cohorts, and for individuals aged ≤75 years (vs older), though only within the first 5 years of follow-up. No interactions with sex, education, or socioeconomic position were observed. DISCUSSION: Modifiable risk and protective factors appear relevant for dementia risk reduction across diverse geographical and sociodemographic groups. HIGHLIGHTS: A two-step individual participant data meta-analysis was conducted. This was done at a global scale using data from 21 ethno-regionally diverse cohorts. The association between a modifiable dementia risk score and dementia was examined. The association was modified by geographical region and age at baseline. Yet, modifiable dementia risk and protective factors appear relevant in all investigated groups and regions.

BACKGROUND: Post-traumatic stress disorder (PTSD) and substance use (tobacco, alcohol, and cannabis) are highly comorbid. Many factors affect this relationship, including sociodemographic and psychosocial characteristics, other prior traumas, and physical health. However, few prior studies have investigated this prospectively, examining new substance use and the extent to which a wide range of factors may modify the relationship to PTSD. METHODS: The Advancing Understanding of RecOvery afteR traumA (AURORA) study is a prospective cohort of adults presenting at emergency departments (N = 2,943). Participants self-reported PTSD symptoms and the frequency and quantity of tobacco, alcohol, and cannabis use at six total timepoints. We assessed the associations of PTSD and future substance use, lagged by one timepoint, using the Poisson generalized estimating equations. We also stratified by incident and prevalent substance use and generated causal forests to identify the most important effect modifiers of this relationship out of 128 potential variables. RESULTS: At baseline, 37.3% (N = 1,099) of participants reported likely PTSD. PTSD was associated with tobacco frequency (incidence rate ratio (IRR): 1.003, 95% CI: 1.00, 1.01, p = 0.02) and quantity (IRR: 1.01, 95% CI: 1.001, 1.01, p = 0.01), and alcohol frequency (IRR: 1.002, 95% CI: 1.00, 1.004, p = 0.03) and quantity (IRR: 1.003, 95% CI: 1.001, 1.01, p = 0.001), but not with cannabis use. There were slight differences in incident compared to prevalent tobacco frequency and quantity of use; prevalent tobacco frequency and quantity were associated with PTSD symptoms, while incident tobacco frequency and quantity were not. Using causal forests, lifetime worst use of cigarettes, overall self-rated physical health, and prior childhood trauma were major moderators of the relationship between PTSD symptoms and the three substances investigated. CONCLUSION: PTSD symptoms were highly associated with tobacco and alcohol use, while the association with prospective cannabis use is not clear. Findings suggest that understanding the different risk stratification that occurs can aid in tailoring interventions to populations at greatest risk to best mitigate the comorbidity between PTSD symptoms and future substance use outcomes. We demonstrate that this is particularly salient for tobacco use and, to some extent, alcohol use, while cannabis is less likely to be impacted by PTSD symptoms across the strata.

Background: Intimate partner violence is more common in polygynous couples than monogamous couples, but the extent that this association is modified by the husband's alcohol consumption is unknown. The objectives of this study are: (1) To describe the extent to which polygyny is associated with self-reported experience of intimate partner violence among women receiving postpartum care; (2) To describe the extent to which the mentioned association is modified by the husband's alcohol consumption. Methods: We conducted a hospital-based cross-sectional study among women age 18 years or older receiving postpartum care at 8 public hospitals in 3 provinces in Northern and Northeastern Thailand using self-administered questionnaires. We analyzed data using descriptive statistics, logistic regression, and stratified analyses. Results: A total of 1207 women agreed to participate in the study, 8% of whom reported that their husbands practiced polygyny. Women in a polygynous relationship were more likely than women in monogamous relationships to experience intimate partner violence (11.7% vs. 3.6%, Adjusted OR = 2.23; 95% CI = 0.94, 5.26). The prevalence of intimate partner violence was relatively low in both groups among women whose husbands did not drink (2.9% vs. 0%, Adjusted OR = N/A), and very high in both groups among those whose husbands binge-drank (46.2% vs. 20.8%, Adjusted OR = 9.54; 95% CI = 1.10, 82.54). However, the Breslow-Day Test of Homogeneity suggested that there was no statistically significant effect modification (p-value = 0.259). Conclusion: Stakeholders in intimate partner violence should consider both alcohol use (particularly binge-drinking) and polygyny as risk factors for intimate partner violence. However, caveats regarding study design, misclassification and potential information bias, and lack of generalizability should be considered in the interpretation of the study findings. [ABSTRACT FROM AUTHOR]

Many older adults experience a major stressor at some point in their lives. The ability to recover well after a major stressor is known as resilience. An important goal of geriatric research is to identify factors that influence resilience to stressors. Studies of resilience in older adults are typically conducted with a single-arm where everyone experiences the stressor. The simplistic approach of regressing change versus baseline yields biased estimates due to mathematical coupling and regression to the mean (RTM). We develop a method to correct the bias. We extend the method to include covariates. Our approach considers a counterfactual control group and involves sensitivity analyses to evaluate different settings of control group parameters. Only minimal distributional assumptions are required. Simulation studies demonstrate the validity of the method. We illustrate the method using a large, registry of older adults (N = 7239) who underwent total knee replacement (TKR). We demonstrate how external data can be utilized to constrain the sensitivity analysis. Naive analyses implicated several treatment effect modifiers including baseline function, age, body-mass index (BMI), gender, number of comorbidities, income, and race. Corrected analysis revealed that baseline (pre-stressor) function was not strongly linked to recovery after TKR and among the covariates, only age and number of comorbidities were consistently and negatively associated with post-stressor recovery in all functional domains. Correction of mathematical coupling and RTM is necessary for drawing valid inferences regarding the effect of covariates and baseline status on pre–post change. Our method provides a simple estimator to this end. [ABSTRACT FROM AUTHOR]

Background: The prevalence of clinically diagnosed depressive disorders (DD) in Chinese left-behind children (LBC) remains unknown. We aim to estimate the prevalence of DD, discuss the associations between DD and self-harm (SH) behaviors in a large representative sample of Chinese LBCs chosen from Yunnan province. Methods: A total of 5462 LBCs were selected from the most recent datasets of the Mental Health Survey for Children and Adolescents in Yunnan (MHSCAY), a mega population-based two-phase cross-sectional survey. Weighted prevalence rates and designed Logistic regression were adopted to estimate the prevalence of DD and the association between DD and SH. Results: The weighted prevalence of lifetime and current DD were 4.22% (95% CI: 3.13-6.00%) and 3.84% (95% CI: 2.85-5.00%) in Chinese LBCs. Higher lifetime and current DD prevalence rates were observed in girls and those reported adverse parental marital status and SH behaviors. The absence of DD was associated with significantly decreased odds of SH behavior (OR = 0.06), repetitive SH (OR = 0.09), using multiple SH methods (OR = 0.09), and severe SH (OR = 0.15). Subsequently performed stratified analyses identified prominent effect modification by sex and age, as a stronger association between DD and SH was found in girls (OR = 0.02 versus OR = 0.07 in boys) and younger adolescents (OR = 0.08 versus OR = 0.22 in older adolescents). Conclusion: The prevalence of DD was high in Chinese LBCs. DD was associated with prominently increased risk of SH behaviors in LBCs. Attention and intervention are needed in this vulnerable population. [ABSTRACT FROM AUTHOR]

Background Due to the heterogeneity of risk for invasive anal cancer (IAC) among people with human immunodeficiency virus (PWH), we investigated predictors of IAC and described outcomes among those with a cancer diagnosis. Methods Using a longitudinal inception cohort of anal cancer screening, we evaluated risk factors and outcome probabilities for incident IAC in Cox models. Screening included anal cytology and digital anorectal examination, and, if results of either were abnormal, high-resolution anoscopy. Results Between 30 November 2006 and 3 March 2021, a total of 8139 PWH received care at the University of California, San Diego, with 4105 individuals undergoing screening and subsequently followed up over a median of 5.5 years. Anal cancer developed in 33 of them. IAC was more likely to develop in patients with anal high-grade squamous intraepithelial lesions (aHSILs) on initial or subsequent follow-up cytology (hazard ratio, 4.54) and a nadir CD4 cell count ≤200/µL (2.99). The joint effect of aHSILs and nadir CD4 cell count ≤200/µL amplified the hazard of IAC by 9-fold compared with the absence of both. PWH with time-updated cytology aHSIL and CD4 cell counts ≤200/µL had 5- and 10-year probabilities of IAC of 3.40% and 4.27%, respectively. Twelve individuals with cancer died, 7 (21% of the total 33) due to cancer progression, and they had clinical stage IIIA or higher cancer at initial diagnosis. Conclusions PWH with both aHSIL and a nadir CD4 cell count ≤200/µL have the highest risk of IAC. PWH who died due to IAC progression had clinical stage IIIA cancer or higher at diagnosis, highlighting the importance of early diagnosis through high-resolution anoscopic screening. [ABSTRACT FROM AUTHOR]

For Black students in the United States, attending schools with a higher proportion of White students is associated with worse mental and physical health outcomes in adolescence/early adulthood. To our knowledge, no prior studies have evaluated the association between school racial/ethnic composition from kindergarten through grade 12 and later-life mental health. In a cohort of Black adults aged ≥50 years in Northern California who retrospectively reported (2017-2020) school racial/ethnic composition for grades 1, 6, 9, and 12, we assessed the association between attending a school with mostly Black students versus not and mid-/late-life depressive symptoms (8-item Patient-Reported Outcomes Measurement Information System (PROMIS) depression score, standardized to the 2000 US adult population) using age-, sex/gender-, southern US birth–, and parental education–adjusted generalized estimating equations, and assessed effect modification by the presence of a caring teacher/staff member. Levels of later-life depressive symptoms were lower among those who attended schools with mostly Black students in grades 1 and 6 (β = −0.12 [95% CI, −0.23 to 0.00] and β = −0.11 [95% CI, −0.22 to 0.00], respectively). In grade 6, this difference was larger for students without an adult at school who cared about them (β = −0.29 [95% CI, −0.51 to −0.07] vs β = −0.04 [95% CI, −0.17 to 0.09]). Among Black Americans, experiencing early schooling with mostly Black students may have later-life mental health benefits; this protective association appears more important for students without the presence of caring teachers/staff. This article is part of a Special Collection on Mental Health. [ABSTRACT FROM AUTHOR]

Respiratory virus infections are related to over 80% of childhood asthma exacerbations. They enhance pro-inflammatory mediator release, especially for sensitized individuals exposed to pollens/molds. Using a time-series study design, we investigated possible effect modification by respiratory virus infections of the associations between aeroallergens/PM2.5 and asthma exacerbation rates. Outpatient, emergency department (ED), and inpatient visits for asthma exacerbation among children with asthma (28,540/24,444 [warm/cold season]), as well as viral infection counts were obtained from electronic health records of the Children's Hospital of Philadelphia from 2011 to 2016. Rate ratios (RRs, 90th percentile vs. 0) for late-season grass pollen were 1.00 (0.85–1.17), 1.04 (0.95–1.15), and 1.12 (0.96–1.32), respectively, for respiratory syncytial virus (RSV) counts within each tertile. However, similar trends were not observed for weed pollens/molds or PM2.5. Overall, our study provides little evidence supporting effect modification by respiratory viral infections. [ABSTRACT FROM AUTHOR]

Objective: Patient‐reported outcome measures, while valuable, may not correlate with diagnostic test results. To better understand this potential discrepancy, our objective was to determine whether psychological health is an effect modifier of the association between patient‐reported allergy outcome scores and allergy test results. Study Design: Prospective outcomes study. Setting: Tertiary care hospital and community‐based clinic. Methods: This study included 600 patients at least 18 years of age who presented for symptoms related to allergic rhinitis and completed the related sinonasal outcome test (SNOT), which includes validated nasal, allergy, and psychological domains. Stratified analyses of odds ratios and Spearman correlation coefficients were utilized to assess for effect modification by psychological status. Results: Worse patient‐reported allergic rhinitis symptoms were significantly associated with positive allergy test results (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.22‐2.34, P =.002) in patients with better psychological health. In contrast, there was no association in patients with worse psychological health (OR 1.06, 95% CI 0.36‐3.10, P =.92). These findings were corroborated by assessments of correlation: allergy domain scores were positively correlated with allergy testing scores (Spearman rho 0.18, 95% CI 0.10‐0.25, P <.001) in patients with better psychological health, while there was no correlation in patients with worse psychological health (−0.02, 95% CI −0.16‐0.12, P =.77). Conclusions: Psychological status was an effect modifier of the association between allergy domain and allergy testing data. When assessing the relationship between subjective measures, such as sinonasal validated instruments, and objective measures, such as allergy test results, accounting for effect modifiers such as psychological state can provide clinical and research‐related insights. [ABSTRACT FROM AUTHOR]

Abstract Background Intimate partner violence is more common in polygynous couples than monogamous couples, but the extent that this association is modified by the husband’s alcohol consumption is unknown. The objectives of this study are: (1) To describe the extent to which polygyny is associated with self-reported experience of intimate partner violence among women receiving postpartum care; (2) To describe the extent to which the mentioned association is modified by the husband’s alcohol consumption. Methods We conducted a hospital-based cross-sectional study among women age 18 years or older receiving postpartum care at 8 public hospitals in 3 provinces in Northern and Northeastern Thailand using self-administered questionnaires. We analyzed data using descriptive statistics, logistic regression, and stratified analyses. Results A total of 1207 women agreed to participate in the study, 8% of whom reported that their husbands practiced polygyny. Women in a polygynous relationship were more likely than women in monogamous relationships to experience intimate partner violence (11.7% vs. 3.6%, Adjusted OR = 2.23; 95% CI = 0.94, 5.26). The prevalence of intimate partner violence was relatively low in both groups among women whose husbands did not drink (2.9% vs. 0%, Adjusted OR = N/A), and very high in both groups among those whose husbands binge-drank (46.2% vs. 20.8%, Adjusted OR = 9.54; 95% CI = 1.10, 82.54). However, the Breslow-Day Test of Homogeneity suggested that there was no statistically significant effect modification (p-value = 0.259). Conclusion Stakeholders in intimate partner violence should consider both alcohol use (particularly binge-drinking) and polygyny as risk factors for intimate partner violence. However, caveats regarding study design, misclassification and potential information bias, and lack of generalizability should be considered in the interpretation of the study findings.

Abstract Background The prevalence of clinically diagnosed depressive disorders (DD) in Chinese left-behind children (LBC) remains unknown. We aim to estimate the prevalence of DD, discuss the associations between DD and self-harm (SH) behaviors in a large representative sample of Chinese LBCs chosen from Yunnan province. Methods A total of 5462 LBCs were selected from the most recent datasets of the Mental Health Survey for Children and Adolescents in Yunnan (MHSCAY), a mega population-based two-phase cross-sectional survey. Weighted prevalence rates and designed Logistic regression were adopted to estimate the prevalence of DD and the association between DD and SH. Results The weighted prevalence of lifetime and current DD were 4.22% (95% CI: 3.13-6.00%) and 3.84% (95% CI: 2.85-5.00%) in Chinese LBCs. Higher lifetime and current DD prevalence rates were observed in girls and those reported adverse parental marital status and SH behaviors. The absence of DD was associated with significantly decreased odds of SH behavior (OR = 0.06), repetitive SH (OR = 0.09), using multiple SH methods (OR = 0.09), and severe SH (OR = 0.15). Subsequently performed stratified analyses identified prominent effect modification by sex and age, as a stronger association between DD and SH was found in girls (OR = 0.02 versus OR = 0.07 in boys) and younger adolescents (OR = 0.08 versus OR = 0.22 in older adolescents). Conclusion The prevalence of DD was high in Chinese LBCs. DD was associated with prominently increased risk of SH behaviors in LBCs. Attention and intervention are needed in this vulnerable population.

Background Numerous studies have linked fine particulate matter (PM2.5) to increased cardiovascular mortality. Less is known how the PM2.5-cardiovascular mortality association varies by use of cardiovascular medications. This study sought to quantify effect modification by statin use status on the associations between long-term exposure to PM2.5 and mortality from any cardiovascular cause, coronary heart disease (CHD), and stroke. Methods In this nested case-control study, we followed 1.2 million community-dwelling adults aged ≥66 years who lived in Ontario, Canada from 2000 through 2018. Cases were patients who died from the three causes. Each case was individually matched to up to 30 randomly selected controls using incidence density sampling. Conditional logistic regression models were used to estimate odds ratios (ORs) for the associations between PM2.5 and mortality. We evaluated the presence of effect modification considering both multiplicative (ratio of ORs) and additive scales (the relative excess risk due to interaction, RERI). Results Exposure to PM2.5 increased the risks for cardiovascular, CHD, and stroke mortality. For all three causes of death, compared with statin users, stronger PM2.5-mortality associations were observed among non-users [e.g. for cardiovascular mortality corresponding to each interquartile range increase in PM2.5, OR = 1.042 (95% CI, 1.032–1.053) vs OR = 1.009 (95% CI, 0.996–1.022) in users, ratio of ORs = 1.033 (95% CI, 1.019–1.047), RERI = 0.039 (95% CI, 0.025–0.050)]. Among users, partially adherent users exhibited a higher risk of PM2.5-associated mortality than fully adherent users. Conclusions The associations of chronic exposure to PM2.5 with cardiovascular and CHD mortality were stronger among statin non-users compared to users. [ABSTRACT FROM AUTHOR]

6:2 chlorinated polyfluorinated ether sulfonate (6:2 Cl-PFESA) exhibits pronounced estrogenic effects, potentially influencing the etiology of lung cancer. This study assessed the potential associations between serum concentrations of 6:2 Cl-PFESA and lung cancer risk at the population level. Odds ratios (ORs) for lung cancer across serum 6:2 Cl-PFESA quartiles were assessed using conditional logistic regression. Additionally, we investigated potential effect modification by various confounding factors. Elevated serum levels of 6:2 Cl-PFESA were consistently associated with an increased risk of lung cancer in both the crude model (OR = 1.62, 95% CI: 1.08–2.42, p = 0.018) and the adjusted model (OR = 1.59, 95% CI: 1.06–2.39, p = 0.026). Stratified analyses revealed that elevated serum levels of 6:2 Cl-PFESA were associated with increased risk estimates of lung cancer among males (adjusted OR = 2.04, 95% CI: 1.19–3.51, p = 0.006), smokers (adjusted OR = 2.48, 95% CI: 1.25–4.89, p = 0.003), and drinkers (adjusted OR = 2.20, 95% CI: 0.94–5.16, p = 0.049). The results of this study imply that exposure to 6:2 Cl-PFESA at levels considered environmentally relevant may be linked to an elevated risk of developing lung cancer. [ABSTRACT FROM AUTHOR]

Importance and objectives The current medical paradigm of evidence-based medicine relies on clinical guidelines derived from randomized clinical trials (RCTs), but these guidelines often overlook individual variations in treatment effects. Approaches have been proposed to develop models predicting the effects of individualized management, such as predictive allocation, individualizing treatment allocation. It is currently unknown whether widespread implementation of predictive allocation could result in better population-level outcomes over guideline-based therapy. We sought to simulate the potential effect of predictive allocation using data from previously conducted RCTs. Methods and results Data from 3 RCTs (positive trial, negative trial, trial stopped for futility) in pediatric cardiology were used in a computational simulation study to quantify the potential benefits of a personalized approach based on predictive allocation. Outcomes were compared when using a universal approach vs predictive allocation where each patient was allocated to the treatment associated with the lowest predicted probability of negative outcome. Compared to results from RCTs, predictive allocation yielded absolute risk reductions of 13.8% (95% confidence interval [CI] −1.9 to 29.5), 13.9% (95% CI 4.5-23.2), and 15.6% (95% CI 1.5-29.6), respectively, corresponding to a number needed to treat of 7.3, 7.2, and 6.4. The net benefit of predictive allocation was directly proportional to the performance of the prediction models and disappeared as model performance degraded below an area under the curve of 0.55. Discussion These findings highlight that predictive allocation could result in improved group-level outcomes, particularly when highly predictive models are available. These findings will need to be confirmed in simulations of other trials with varying conditions and eventually in RCTs of predictive vs guideline-based treatment allocation. [ABSTRACT FROM AUTHOR]

There is limited long-term evidence on the effects of COVID-19 on vascular injury between male and female sex. An adult cohort of COVID-19 survivors (COVID+) and confirmed SARS-CoV-2 antibody-negative participants (COVID-) were prospectively enrolled. COVID+ participants who have documented the presence of persistent symptoms four weeks following infection were considered to have post-acute sequelae of COVID-19 (PASC). Non-invasive, FDA-approved EndoPAT (Endo-PAT2000) was used for endothelial assessment. COVID-(n = 94) were 1:1 propensity score matched to COVID+ (n = 151) on baseline covariates including sex. Among COVID+, 66.2% (n = 100) had PASC. Higher levels of coagulation marker, D-dimer (p = 0.001), and gut permeability marker, zonulin (p = 0.001), were associated with female sex. Estimated differences in augmentation index (AI) between COVID− (0.9 ± 17.2) and COVID+ (8.4 ± 15.7; p = 0.001) and between female and male sex (12.9 ± 1.9; p <.0001) were observed. Among COVID+ with PASC, the average AI (10.5 ± 1.6) was 9.7 units higher than COVID− (p <.0001) and 6.2 units higher compared to COVID+ with no PASC (p = 0.03). COVID+ PASC+ female sex had the highest AI (14.3 ± 1.9). The effects of SARS-CoV-2 infection on vascular function varies across strata of sex and female sex in the post-acute phase of COVID-19 have the worse arterial elasticity (highest AI). [ABSTRACT FROM AUTHOR]

Background and Objectives: In the context of disease prevention, interaction on an additive scale is commonly assessed to determine synergistic effects between exposures. While the "Relative Excess Risk due to Interaction" represents the main measure of additive interaction between risk factors, in this study we aimed to extend this approach to assess additive interaction between factors known to prevent the event's occurrence, such as medical interventions and drugs. Materials and Methods: We introduced and described the "Relative Risk Reduction due to Interaction" (RRRI) as a key measure to assess additive interactions between preventive factors, such as therapeutic interventions and drug combinations. For RRRI values closer to 1, the combination of exposures has a greater impact on reducing the event risk due to their interaction. As a purely illustrative example, we re-evaluated a previous investigation of the synergistic effect between statins and blood pressure-lowering drugs in preventing major adverse cardiovascular events (MACE). Moreover, simulation studies were used to empirically evaluate the performance of a robust Poisson regression model to estimate RRRI across different scenarios. Results: In our example, the drug combination revealed a positive additive interaction in further reducing MACE risk (RRRI > 0), even if not statistically significant. This result is more straightforward to interpret as compared to the original one based on the RERI. Additionally, our simulations highlighted the importance of large sample sizes for detecting significant interaction effects. Conclusion: We recommend RRRI as the main measure to be considered when exploring additive interaction effects between protective exposures, such as the investigation of synergistic effects between drug combinations or preventive treatments. [ABSTRACT FROM AUTHOR]

Evidence on the association between red meat consumption and lung cancer risk is weak. This study examined the associations between red meat and lung cancer across levels of antioxidant intake from foods or supplements. Cox proportional hazard models were applied to assess hazard ratios (HRs) for lung cancer incidence in the Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer screening trial. Baseline food frequency questionnaires measured red meat and antioxidant intake. The food-based Composite Dietary Antioxidant Index (fCDAI) evaluated the overall natural intake of vitamin A, vitamin C, vitamin E, zinc, magnesium, and selenium. During 13 years of follow-up, 95,647 participants developed 1599 lung cancer cases. Higher red meat consumption was associated with a higher risk of lung cancer (HRQ4vsQ1 1.43, 95%CI 1.20–1.71, p-trend < 0.001). We observed similar trends across groups with low or medium levels of antioxidant intake. However, no association was noticed in the group with the highest fCDAI (HRQ4vsQ1 1.24, 95%CI 0.90–1.72, p-trend = 0.08) and highest independent natural antioxidant intake. The attenuated risk was not consistently observed among groups with high supplement use. Lastly, we did not notice evidence of interactions between red meat and antioxidant intake. Our findings emphasize the importance of limiting red meat in lung cancer prevention. [ABSTRACT FROM AUTHOR]

Effect modification plays a central role in stratified medicine, of which the goal is often to find biomarker profiles that identify individuals who benefit from a treatment of interest. We consider the problem of causal inference regarding the effect modifying role of a biomarker, which is only available for some individuals in an observational study. We develop inverse probability weighted mean score estimating functions with one weight to account for confounding and a second weight for the missing data process. An iterative approach is described for solving the equations in the spirit of the expectation-maximization algorithm, and large sample properties of the resulting estimator are developed. Simulation studies are conducted to compare the proposed method with a doubly weighted complete case analysis and a propensity score weighted multiple imputation approach. An application to a study of the effect of a biologic therapy on inflammation in a rheumatology cohort is given for illustration. [ABSTRACT FROM AUTHOR]

Background The risk of failure associated with different surgical strategies for prosthetic joint infections (PJIs) among patients with and without Staphylococcus aureus is uncertain. The purpose of this study was to assess whether S. aureus modifies the association between retained hardware and failure following revision surgery for PJI of the knee. Methods This was a single-center retrospective cohort study of 106 first PJIs of the knee between 2016 and 2020 at a rural academic medical center. The exposure was retained hardware following revision surgery for PJI, and the outcomes were recurrent infection, any infection, and a composite outcome including any infection, unplanned revision, failure to undergo reimplantation, amputation, or death within 2 years of revision. We used negative binomial regression to quantify the association between the exposure and outcome and to assess the presence of S. aureus as an effect modifier. Results Retained hardware was significantly associated with failure when defined as recurrent infection among S. aureus PJI (adjusted risk difference [aRD], 0.38; 95% CI, 0.12–0.64) but not in the absence of S. aureus (aRD, −0.02; 95% CI, −0.17 to 0.13), and S. aureus was an effect modifier (P interaction =.01). Conclusions We report a significant association between the presence of retained hardware and recurrent infection among S. aureus PJI of the knee, but not for non– S. aureus PJI. This could help inform the surgical management of PJI of the knee in cases where the microbiology is known before surgery. [ABSTRACT FROM AUTHOR]

Limited knowledge is available about the association between autistic spectrum disorder (ASD) and precocious puberty. Our study examined the association between the two medical conditions and effect modification by sex and neuropsychiatric comorbidities in a nationwide population. To compare the risk of precocious puberty between ASD and non-ASD cases, we conducted a Cox regression analysis using ASD as the exposure and time to precocious puberty as the outcome. We adjusted for sex, attention-deficit/hyperactivity disorder (ADHD), tic disorder, obsessive–compulsive disorder (OCD), anxiety disorder, intellectual disability, and epilepsy. We performed a moderation analysis to examine the potential moderating effects of sex and comorbidities. Patients with ASD were prone to have precocious puberty, with an adjusted hazard ratio (aHR) of 1.80 (95% CI: 1.61–2.01). For effect modification, sex, specifically females, moderated the association between ASD and precocious puberty, with a relative excess risk due to interaction (RERI) of 7.35 (95% CI 4.90–9.80). No significant effect modification was found for any of the comorbidities within the scope of additive effect modification. We found that patients with ASD were prone to precocious puberty, regardless of sex or comorbid neuropsychiatric disorders. Girls with ASD are at a particularly higher risk of developing precocious puberty. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The LIfestyle for BRAin Health (LIBRA) index yields a dementia risk score based on modifiable lifestyle factors and is validated in Western samples. We investigated whether the association between LIBRA scores and incident dementia is moderated by geographical location or sociodemographic characteristics. METHODS: We combined data from 21 prospective cohorts across six continents (N = 31,680) and conducted cohort‐specific Cox proportional hazard regression analyses in a two‐step individual participant data meta‐analysis. RESULTS: A one‐standard‐deviation increase in LIBRA score was associated with a 21% higher risk for dementia. The association was stronger for Asian cohorts compared to European cohorts, and for individuals aged ≤75 years (vs older), though only within the first 5 years of follow‐up. No interactions with sex, education, or socioeconomic position were observed. DISCUSSION: Modifiable risk and protective factors appear relevant for dementia risk reduction across diverse geographical and sociodemographic groups. Highlights: A two‐step individual participant data meta‐analysis was conducted.This was done at a global scale using data from 21 ethno‐regionally diverse cohorts.The association between a modifiable dementia risk score and dementia was examined.The association was modified by geographical region and age at baseline.Yet, modifiable dementia risk and protective factors appear relevant in all investigated groups and regions. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to assess the association between affordability in terms of difficulty paying dental bills in Australian dollars and dental service use in the presence of sociodemographic confounders, and to assess the role of dental anxiety and satisfaction with dental professionals as mediators. The second aim was to investigate how dental anxiety and satisfaction with dental professionals modify the association between affordability and use of dental services in Australian adults. Methods: Longitudinal data from the Australian National Study of Adult Oral Health (2004–06 and 2017–18) was used. Poisson regression and path analysis were conducted to determine the association between affordability and frequency of use of dental services. Effect measure modification (EMM) analysis was performed by stratification of dental anxiety and satisfaction with dental professionals. Results: The study included 1698 Australian adults and identified that the prevalence of low frequency of dental visits was 20% more for those who had difficulty paying dental bills. Adults with dental anxiety (prevalence ratio [PR] = 1.14) and those who were dissatisfied with dental professionals (PR = 1.17) had a higher prevalence of low frequency of dental visits in the presence of difficulty paying dental bills. This indicated that dental anxiety and dissatisfaction with dental professionals were effect modifiers on this pathway. Conclusions: Adults who experience dental anxiety and dissatisfaction with dental professionals are more likely to avoid dental visits when faced with difficulty paying dental bills. However, it is important to note that these associations do not necessarily imply a causal relationship. [ABSTRACT FROM AUTHOR]

Maternal exposure to air pollution during pregnancy has a substantial public health impact. Epidemiological evidence supports an association between maternal exposure to air pollution and low birth weight. A popular method to estimate this association while identifying windows of susceptibility is a distributed lag model (DLM), which regresses an outcome onto exposure history observed at multiple time points. However, the standard DLM framework does not allow for modification of the association between repeated measures of exposure and the outcome. We propose a distributed lag interaction model that allows modification of the exposure‐time‐response associations across individuals by including an interaction between a continuous modifying variable and the exposure history. Our model framework is an extension of a standard DLM that uses a cross‐basis, or bi‐dimensional function space, to simultaneously describe both the modification of the exposure‐response relationship and the temporal structure of the exposure data. Through simulations, we showed that our model with penalization out‐performs a standard DLM when the true exposure‐time‐response associations vary by a continuous variable. Using a Colorado, USA birth cohort, we estimated the association between birth weight and ambient fine particulate matter air pollution modified by an area‐level metric of health and social adversities from Colorado EnviroScreen. [ABSTRACT FROM AUTHOR]

Few studies have assessed extreme temperatures' impact on gestational diabetes mellitus (GDM). We examined the relation between GDM risk with weekly exposure to extreme high and low temperatures during the first 24 weeks of gestation and assessed potential effect modification by microclimate indicators.MethodsWe utilized 2008-2018 data for pregnant women from Kaiser Permanente Southern California electronic health records. GDM screening occurred between 24 and 28 gestational weeks for most women using the Carpenter-Coustan criteria or the International Association of Diabetes and Pregnancy Study Groups criteria. Daily maximum, minimum, and mean temperature data were linked to participants' residential address. We utilized distributed lag models, which assessed the lag from the first to the corresponding week, with logistic regression models to examine the exposure-lag-response associations between the 12 weekly extreme temperature exposures and GDM risk. We used the relative risk due to interaction (RERI) to estimate the additive modification of microclimate indicators on the relation between extreme temperature and GDM risk.ResultsGDM risks increased with extreme low temperature during gestational weeks 20--24 and with extreme high temperature at weeks 11-16. Microclimate indicators modified the influence of extreme temperatures on GDM risk. For example, there were positive RERIs for high-temperature extremes and less greenness, and a negative RERI for low-temperature extremes and increased impervious surface percentage.DiscussionSusceptibility windows to extreme temperatures during pregnancy were observed. Modifiable microclimate indicators were identified that may attenuate temperature exposures during these windows, which could in turn reduce the health burden from GDM.

A number of biocidal disinfectant chemicals are used as household products to prevent spread of pathogens. People are commonly exposed to multiple chemicals through those disinfectants. However, effects of interactions (e.g., synergism) between disinfectants on human health outcomes have been rarely studied. In this study, we aimed to investigate associations of a mixture of chloromethylisothiazolinone/methylisothiazolinone (CMIT/MIT) and polyhexamethylene guanidine (PHMG), which had been used as humidifier disinfectants (HDs) in South Korea, with HD-associated lung injury (HDLI) in a Korean population (n = 4058) with HD exposure through use of HD products. Exposure to HD was retrospectively assessed by an interview-based standardized survey, and HDLI was determined by clinical assessment. After adjusting for covariates, PHMG-specific exposure indices (e.g., amount of use, indoor air concentration, and weekly exposure level) were dose-dependently associated with HDLI (their odds ratios for the comparison of third tertile versus first tertile were 1.95, 1.77, and 2.16, respectively). CMIT/MIT exposure was not observed to have a significant association with HDLI in a single chemical exposure model; however, associations between PHMG exposure and HDLI were strengthened by co-exposure to CMIT/MIT in combined chemical exposure models, where synergistic interactions between CMIT/MIT use and PHMG indices (amount of use and weekly exposure level) were observed (p-interaction in additive scale: 0.02 and 0.03, respectively). Our findings imply that adverse effects of PHMG exposure on lung injury among HD users might be worsened by co-exposure to CMIT/MIT. Given that plenty of household products contain disinfectants on global markets, epidemiological and toxicological investigations are warranted on interaction effects of co-exposure to disinfectants. [ABSTRACT FROM AUTHOR]

The purpose of this study was to explore the optimal timing and associated risks of pediatric spinal deformity surgery during the coronavirus disease 2019 (COVID-19) pandemic. All consecutive surgical cases for spinal deformity between September 2022 and May 2023 were included. The population was divided into several categories according to the time from diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to the day of surgery. Postoperative complications were analyzed using logistic regression, and we simultaneously showed the results from the crude model, minimally adjusted model, and fully adjusted model. A total of 81 consecutive patients were enrolled. In the fully adjusted model, compared with pre-COVID-19 patients, peri-COVID-19 patients had a 4.5-fold increased risk of postoperative complications (odds ratio = 5.5, 95% confidence interval 1.1–27.2, P = 0.037), early post-COVID-19 patients had a 2.3-fold increased risk (odds ratio= 3.3, 95% confidence interval 0.7–16.1, P = 0.133), and late post-COVID-19 patients were at essentially equal risk. In asymptomatic population, early post-COVID-19 patients and late post-COVID-19 patients appeared to be at equal risk compared with pre-COVID-19 patients. For patients with persistent symptoms, is necessary to wait at least 8 weeks or even longer after SARS-CoV-2 infection. Interaction tests demonstrated that the effect of the timing of surgery on postoperative complications significantly differed in populations with different symptoms. Surgery for pediatric spinal deformity should be postponed until 8 weeks after SARS-CoV-2 infection in cases with COVID-19-related symptoms within 2 weeks prior to surgery; whereas, for those who are asymptomatic within 2 weeks prior to surgery, an interval of 4 weeks seemed to be sufficient. [ABSTRACT FROM AUTHOR]

Cytomegalovirus (CMV)-seronegative lung transplant recipients (LTRs) with seropositive donors (CMV D+/R−) have the highest mortality of all CMV serostatuses. Due to immunosenescence and other factors, we hypothesized CMV D+/R− status might disproportionately impact older LTRs. Thus, we investigated whether recipient age modified the relationship between donor CMV status and mortality among CMV-seronegative LTRs. Adult, CMV-seronegative first-time lung-only recipients were identified through the Scientific Registry of Transplant Recipients between May 2005 and December 2019. We used adjusted multivariable Cox regression to assess the relationship of donor CMV status and death. Interaction between recipient age and donor CMV was assessed via likelihood ratio testing of nested Cox models and by the relative excess risk due to interaction (RERI) and attributable proportion (AP) of joint effects. We identified 11,136 CMV-seronegative LTRs. The median age was 59 years; 65.2% were male, with leading transplant indication of idiopathic pulmonary fibrosis (35.6%); and 60.8% were CMV D+/R−. In multivariable modeling, CMV D+/R− status was associated with 27% increased hazard of death (adjusted hazard ratio: 1.27, 95% confidence interval: 1.21-1.34) compared to CMV D−/R−. Recipient age ≥60 years significantly modified the relationship between donor CMV-seropositive status and mortality on the additive scale, including RERI 0.24 and AP 11.4% (p = 0.001), that is, the interaction increased hazard of death by 0.24 and explained 11.4% of mortality in older CMV D+ recipients. Among CMV-seronegative LTRs, donor CMV-seropositive status confers higher risk of posttransplant mortality, which is amplified in older recipients. Future studies should define optimal strategies for CMV prevention and management in older D+/R− LTRs. [ABSTRACT FROM AUTHOR]

This study evaluates whether social interaction level modifies the association between frailty and cognitive decline in older adults. A total of 2701 adults aged ≥65 years enrolled in the Progetto Veneto Anziani (Pro.V.A.), participated in the study. At baseline, participants were classified as having low, moderate, or high social interactions based on: cohabiting status, frequency of contacts with relatives/friends or involvement in childcare activities, and frequency of participation in social or community activities. Baseline frailty was defined as the presence of ≥3 criteria among: weight loss, weakness, slowness, low physical activity, and exhaustion. Cognitive function was assessed through the Mini-Mental State Examination (MMSE) at baseline and after 4.4 and 7 years. The association between frailty and MMSE changes over time was evaluated through linear mixed models. Interaction and subgroup analyses explored the modifying effect of social interaction level on the above association. The mean age of participants was 76.1 years, and 59.1% were women. Frail individuals had a steeper annual MMSE decline than their non-frail counterparts (ß=-0.40, 95%CI: −0.59, −0.20). When stratifying participants by social interaction level, we found that the association between frailty and MMSE changes over time was stronger in those with low social interactions (ß=-0.74, 95%CI: −1.33, −0.15) while attenuated in those with moderate (ß=-0.42, 95%CI: −0.74, −0.11) or high social interaction level (ß=-0.29, 95%CI: −0.58, 0.01). Maintaining frequent social interactions might mitigate the negative impact of frailty on older people's cognitive functions. [ABSTRACT FROM AUTHOR]

Background: Post-traumatic stress disorder (PTSD) and substance use (tobacco, alcohol, and cannabis) are highly comorbid. Many factors affect this relationship, including sociodemographic and psychosocial characteristics, other prior traumas, and physical health. However, few prior studies have investigated this prospectively, examining new substance use and the extent to which a wide range of factors may modify the relationship to PTSD. Methods: The Advancing Understanding of RecOvery afteR traumA (AURORA) study is a prospective cohort of adults presenting at emergency departments (N = 2,943). Participants self-reported PTSD symptoms and the frequency and quantity of tobacco, alcohol, and cannabis use at six total timepoints. We assessed the associations of PTSD and future substance use, lagged by one timepoint, using the Poisson generalized estimating equations. We also stratified by incident and prevalent substance use and generated causal forests to identify the most important effect modifiers of this relationship out of 128 potential variables. Results: At baseline, 37.3% (N = 1,099) of participants reported likely PTSD. PTSD was associatedwith tobacco frequency (incidence rate ratio (IRR): 1.003, 95% CI: 1.00, 1.01, p = 0.02) and quantity (IRR: 1.01, 95% CI: 1.001, 1.01, p = 0.01), and alcohol frequency (IRR: 1.002, 95% CI: 1.00, 1.004, p = 0.03) and quantity (IRR: 1.003, 95% CI: 1.001, 1.01, p = 0.001), but not with cannabis use. There were slight differences in incident compared to prevalent tobacco frequency and quantity of use; prevalent tobacco frequency and quantity were associated with PTSD symptoms, while incident tobacco frequency and quantity were not. Using causal forests, lifetime worst use of cigarettes, overall self-rated physical health, and prior childhood trauma were major moderators of the relationship between PTSD symptoms and the three substances investigated. Conclusion: PTSD symptoms were highly associated with tobacco and alcohol use, while the association with prospective cannabis use is not clear. Findings suggest that understanding the different risk stratification that occurs can aid in tailoring interventions to populations at greatest risk to best mitigate the comorbidity between PTSD symptoms and future substance use outcomes. We demonstrate that this is particularly salient for tobacco use and, to some extent, alcohol use, while cannabis is less likely to be impacted by PTSD symptoms across the strata. [ABSTRACT FROM AUTHOR]

Background: Studies have suggested Medicaid expansion enacted in 2014 has resulted in a reduction in overall cardiovascular disease (CVD) mortality in the United States. However, it is unknown whether Medicaid expansion has a similar effect across race-ethnicity and sex. We investigated the effect of Medicaid expansion on CVD mortality across race-ethnicity and sex. Methods: Data come from the behavioral risk factor surveillance system and the US Centers for Disease Control's Wide-ranging Online Data for Epidemiologic Research, spanning the period 2000-2019. We used the generalized synthetic control method, a quasiexperimental approach, to estimate effects. Results: Medicaid expansion was associated with -5.36 (mean difference [MD], 95% confidence interval [CI] = -22.63, 11.91) CVD deaths per 100,000 persons per year among Blacks; -4.28 (MD, 95% CI = -30.08, 21.52) among Hispanics; -3.18 (MD, 95% CI = -8.30, 1.94) among Whites; -5.96 (MD, 95% CI = -15.42, 3.50) among men; and -3.34 (MD, 95% CI = -8.05, 1.37) among women. The difference in mean difference (DMD) between the effect of Medicaid expansion in Blacks compared with Whites was -2.18; (DMD, 95% CI = -20.20, 15.83); between that in Hispanics compared with Whites: -1.10; (DMD, 95% CI = -27.40, 25.20) and between that in women compared with men: 2.62; (DMD, 95% CI = -7.95, 13.19). Conclusions: Medicaid expansion was associated with a reduction in CVD mortality overall and in White, Black, Hispanic, male, and female subpopulations. Also, our study did not find any difference or disparity in the effect of Medicaid on CVD across race-ethnicity and sex-gender subpopulations, likely owing to imprecise estimates. [ABSTRACT FROM AUTHOR]

It is unclear whether Gross Domestic Product (GDP) and greenness have additional modifying effects on the association between air pollution and respiratory system disease. Utilizing a time‐stratified case‐crossover design with a distributed lag linear model, we analyzed the association between six pollutants (PM2.5, PM10, NO2, SO2, O3, and CO) and 555,498 respiratory hospital admissions in Beijing from 1st January 2016 to 31st December 2019. We employed conditional logistic regression, adjusting for meteorological conditions, holidays and influenza, to calculate percent change of hospitalization risk. Subsequently, we performed subgroup analysis to investigate potential effect modifications using a two‐sample z test. Every 10 μg/m3 increase in PM2.5, PM10, NO2, SO2, and O3 led to increases of 0.26% (95%CI: 0.17%, 0.35%), 0.15% (95%CI: 0.09%, 0.22%), 0.61% (95%CI: 0.44%, 0.77%), 1.72% (95%CI: 1.24%, 2.21%), and 0.32% (95%CI: 0.20%, 0.43%) in admissions, respectively. Also, a 1 mg/m3 increase in CO levels resulted in a 2.50% (95%CI: 1.96%, 3.04%) rise in admissions. The links with NO2 (p < 0.001), SO2 (p < 0.001), O3 (during the warm season, p < 0.001), and CO (p < 0.001) were significantly weaker among patients residing in areas with higher levels of greenness. No significant modifying role of GDP was observed. Greenness can help mitigate the effects of air pollutants, while the role of GDP needs further investigation. Plain Language Summary: Numerous investigations have explored the connection between air pollution and respiratory disease hospital admissions. Nonetheless, the potential modifying roles of Gross Domestic Product (GDP) and the presence of green spaces remain inconclusive. To address this issue, our research utilized a time‐stratified case‐crossover design, analyzing electronic patient records from Beijing, China's capital city. Our analysis did not reveal any significant alteration in the relationship between air pollution and respiratory disease admissions due to sex or GDP. However, the data indicated that the correlation was amplified for individuals aged over 65, during different seasons, for those with differing marital statuses, and among those residing in areas with low greenness (Normalized Difference Vegetation Index levels). Drawing from an extensive data set, these results offer more detailed insight into strategies to mitigate the effects of air pollution on respiratory disease‐related hospital admissions. Key Points: Six pollutants have adverse effects, with O3 exerting adverse effects only in the warm seasonGreenness has a modifying effect on the detrimental impact of NO2, SO2, O3 (warm), and CONo moderating effect of Gross Domestic Product was found [ABSTRACT FROM AUTHOR]

IntroductionInformal caregiving is a critical component of the healthcare system despite numerous impacts on informal caregivers’ health and well-being. Racial and gender disparities in caregiving duties and health outcomes are well documented. Place-based factors, such as neighborhood conditions and rural–urban status, are increasingly being recognized as promoting and moderating health disparities. However, the potential for place-based factors to interact with racial and gender disparities as they relate to caregiving attributes jointly and differentially is not well established. Therefore, the primary objective of this study was to jointly assess the variability in caregiver health and aspects of the caregiving experience by race/ethnicity, sex, and rural–urban status.MethodsThe study is a secondary analysis of data from the 2021 and 2022 Behavioral Risk Factor Surveillance System (BRFSS) from the Centers for Disease Control and Prevention. Multivariable logistic regression or Poisson regression models assessed differences in caregiver attributes and health measures by demographic group categorized by race/ethnicity, sex, and rural–urban status.ResultsRespondents from rural counties were significantly more likely to report poor or fair health (23.2% vs. 18.5%), have obesity (41.5% vs. 37.1%), and have a higher average number of comorbidities than urban caregivers. Overall, rural Black male caregivers were 43% more likely to report poor or fair health than White male caregivers (OR 1.43, 95% CI 1.21, 1.69). Urban female caregivers across all racial groups had a significantly higher likelihood of providing care to someone with Alzheimer’s disease than rural White males (p

ObjectiveTo evaluate the associations between 10 well-established ovarian cancer risk factors and risk of ovarian cancer among women with vs. without endometriosis.DesignPooled analysis of 9 case-control studies in the Ovarian Cancer Association Consortium.SettingPopulation-based.Patient(s)We included 8,500 women with ovarian cancer, 13,592 control women.Intervention(s)Ten well-established ovarian cancer risk factors.Main outcome measure(s)Risk of ovarian cancer for women with and without endometriosis.Result(s)Most risk factor-ovarian cancer associations were similar when comparing women with and without endometriosis, and no interactions were statistically significant. However, body mass index (BMI) 25-

BackgroundMaternal exposure to air pollution has been associated with birth outcomes; however, few studies examined biologically critical exposure windows shorter than trimesters or potential effect modifiers.ObjectivesTo examine associations of prenatal fine particulate matter (PM2.5), by trimester and in biologically critical windows, with birth outcomes and assess potential effect modifiers.MethodsThis study used two pregnancy cohorts (CANDLE and TIDES; N = 2099) in the ECHO PATHWAYS Consortium. PM2.5 was estimated at the maternal residence using a fine-scale spatiotemporal model, averaged over pregnancy, trimesters, and critical windows (0-2 weeks, 10-12 weeks, and last month of pregnancy). Outcomes were preterm birth (PTB,

Abstract Background Hyperuricemia has placed an immense burden on the global healthcare system. Studies have discovered a close correlation between serum uric acid (SUA) and insulin resistance (IR). The objective of this investigation is to examine the association between the triglyceride-glucose (TyG) index, a simple surrogate for IR, and the presence of hyperuricemia. Methods Between 2017 and 2021, an epidemiologic study was conducted on Royal Thai Army (RTA) personnel aged 35–60 years, involving a total of 231,286 participants. In the study, hyperuricemia was defined as a SUA level of 7 mg/dL and 6 mg/dL among male and female participants, respectively. Using linear regression analysis and logistic regression analysis, the association between the TyG index and SUA was determined. Results A positive relationship was demonstrated between the TyG index and the SUA. Overall, SUA increased by 0.32 per unit of TyG index growth (95% CI: 0.31–0.32). In comparison with the first quartile, employees in the fourth TyG quartile had a greater likelihood of having hyperuricemia [adjusted odds ratio (AOR): 2.45, 95% CI: 2.38–2.52]. Effect modification by obesity on the association between the TyG index and SUA was observed (P-interaction

Abstract Background Redlining has been associated with worse health outcomes and various environmental disparities, separately, but little is known of the interaction between these two factors, if any. We aimed to estimate whether living in a historically-redlined area modifies the effects of exposures to ambient PM2.5 and extreme heat on mortality by non-external causes. Methods We merged 8,884,733 adult mortality records from thirteen state departments of public health with scanned and georeferenced Home Owners Loan Corporation (HOLC) maps from the University of Richmond, daily average PM2.5 from a sophisticated prediction model on a 1-km grid, and daily temperature and vapor pressure from the Daymet V4 1-km grid. A case-crossover approach was used to assess modification of the effects of ambient PM2.5 and extreme heat exposures by redlining and control for all fixed and slow-varying factors by design. Multiple moving averages of PM2.5 and duration-aware analyses of extreme heat were used to assess the most vulnerable time windows. Results We found significant statistical interactions between living in a redlined area and exposures to both ambient PM2.5 and extreme heat. Individuals who lived in redlined areas had an interaction odds ratio for mortality of 1.0093 (95% confidence interval [CI]: 1.0084, 1.0101) for each 10 µg m−3 increase in same-day ambient PM2.5 compared to individuals who did not live in redlined areas. For extreme heat, the interaction odds ratio was 1.0218 (95% CI 1.0031, 1.0408). Conclusions Living in areas that were historically-redlined in the 1930’s increases the effects of exposures to both PM2.5 and extreme heat on mortality by non-external causes, suggesting that interventions to reduce environmental health disparities can be more effective by also considering the social context of an area and how to reduce disparities there. Further study is required to ascertain the specific pathways through which this effect modification operates and to develop interventions that can contribute to health equity for individuals living in these areas.

Abstract Background Sexual minority status is associated with face-to-face bullying and cyberbullying victimization. However, limited studies have investigated whether such a relationship differs by sex or grade in a nationally representative sample. Methods We concatenated the national high school data from the Youth Risk Behavior Surveillance System (YRBSS) chronologically from 2015 to 2019, resulting in a sample of 32,542 high school students. We constructed models with the interaction term between sexual minority status and biological sex assigned at birth to test the effect modification by sex on both the multiplicative and additive scales. A similar method was used to test the effect modification by grade. Results Among heterosexual students, females had a higher odds of being bullied than males, while among sexual minority students, males had a higher odds of being bullied. The effect modification by sex was significant on both the multiplicative and additive scales. We also found a decreasing trend of bullying victimization as the grade increased among both heterosexual and sexual minority students. The effect modification by the grade was significant on both the multiplicative and the additive scale. Conclusions Teachers and public health workers should consider the difference in sex and grade when designing prevention programs to help sexual minority students.

Abstract Background The independent effects of short-term exposure to increased air temperature and air pollution on mortality are well-documented. There is some evidence indicating that elevated concentrations of air pollutants may lead to increased heat-related mortality, but this evidence is not consistent. Most of these effects have been documented through time-series studies using city-wide data, rather than at a finer spatial level. In our study, we examined the possible modification of the heat effects on total and cause-specific mortality by air pollution at municipality level in the Attica region, Greece, during the warm period of the years 2000 to 2016. Methods A municipality-specific over-dispersed Poisson regression model during the warm season (May–September) was used to investigate the heat effects on mortality and their modification by air pollution. We used the two-day average of the daily mean temperature and daily mean PM10, NO2 and 8 hour-max ozone (O3), derived from models, in each municipality as exposures. A bivariate tensor smoother was applied for temperature and each pollutant alternatively, by municipality. Α random-effects meta-analysis was used to obtain pooled estimates of the heat effects at different pollution levels. Heterogeneity of the between-levels differences of the heat effects was evaluated with a Q-test. Results A rise in mean temperature from the 75th to the 99th percentile of the municipality-specific temperature distribution resulted in an increase in total mortality of 12.4% (95% Confidence Interval (CI):7.76–17.24) on low PM10 days, and 21.25% (95% CI: 17.83–24.76) on high PM10 days. The increase on mortality was 10.09% (95% CI: − 5.62- 28.41) on low ozone days, and 14.95% (95% CI: 10.79–19.27) on high ozone days. For cause-specific mortality an increasing trend of the heat effects with increasing PM10 and ozone levels was also observed. An inconsistent pattern was observed for the modification of the heat effects by NO2, with higher heat effects estimated in the lower level of the pollutant. Conclusions Our results support the evidence of elevated heat effects on mortality at higher levels of PM10 and 8 h max O3. Under climate change, any policy targeted at lowering air pollution levels will yield significant public health benefits.

Abstract Background The adverse effect of air pollution on mortality is well documented worldwide but the identification of more vulnerable populations at higher risk of death is still limited. The aim of this study was to evaluate the association between natural mortality (overall and cause-specific) and short-term exposure to five air pollutants (PM2.5, PM10, NO2, O3 and black carbon) and identify potential vulnerable populations in Belgium. Methods We used a time-stratified case-crossover design with conditional logistic regressions to assess the relationship between mortality and air pollution in the nine largest Belgian agglomerations. Then, we performed a random-effect meta-analysis of the pooled results and described the global air pollution-mortality association. We carried out stratified analyses by individual characteristics (sex, age, employment, hospitalization days and chronic preexisting health conditions), living environment (levels of population density, built-up areas) and season of death to identify effect modifiers of the association. Results The study included 304,754 natural deaths registered between 2010 and 2015. We found percentage increases for overall natural mortality associated with 10 μg/m3 increases of air pollution levels of 0.6% (95% CI: 0.2%, 1.0%) for PM2.5, 0.4% (0.1%, 0.8%) for PM10, 0.5% (-0.2%, 1.1%) for O3, 1.0% (0.3%, 1.7%) for NO2 and 7.1% (-0.1%, 14.8%) for black carbon. There was also evidence for increases of cardiovascular and respiratory mortality. We did not find effect modification by individual characteristics (sex, age, employment, hospitalization days). However, this study suggested differences in risk of death for people with preexisting conditions (thrombosis, cardiovascular diseases, asthma, diabetes and thyroid affections), season of death (May–September vs October–April) and levels of built-up area in the neighborhood (for NO2). Conclusions This work provided evidence for the adverse health effects of air pollution and contributed to the identification of specific population groups. These findings can help to better define public-health interventions and prevention strategies.

Background: The acute effects of temperature and air pollution on mortality are well-known environmental factors that have been receiving more recognition lately. However, the health effects resulting from the interaction of air pollution and temperature remain uncertain, particularly in cities with low levels of pollution. This study aims to examine the modification effects of particulate matter with a diameter of 2.5 µm or less (PM2.5) and ozone (O3) on the association between temperature and mortality. Methods: We collected the daily number of all-cause, cardiovascular, and respiratory mortality from 20 major cities in Japan from 2012–2018. We obtained meteorological data from the Japan Meteorological Agency and air pollution data from the National Institute for Environmental Studies. We conducted analyses using a quasi-Poisson regression model with a distributed lag non-linear model for temperature in each city and subsequently performed a random-effects meta-analysis to derive average estimates. Results: We found that high levels of O3 might positively modify the mortality risk of heat exposure, especially for cardiovascular diseases. Subgroups such as the elderly and females were susceptible. We did not observe consistent evidence of effect modification by PM2.5, including effect modification on cold by both pollutants. Conclusion: PM2.5 and O3 may positively modify the short-term association between heat and mortality in the urban areas of Japan. These results highlight the need for public health policies and interventions to address the collective impacts of both temperature and air pollution.

BackgroundEstimates of effect heterogeneity (i.e. the extent to which the causal effect of one exposure varies across strata of a second exposure) can be biased if the exposure-outcome relationship is subject to uncontrolled confounding whose severity differs across strata of the second exposure.MethodsWe propose methods, analogous to the E-value for total effects, that help to assess the sensitivity of effect heterogeneity estimates to possible uncontrolled confounding. These E-value analogues characterize the severity of uncontrolled confounding strengths that would be required, hypothetically, to 'explain away' an estimate of multiplicative or additive effect heterogeneity in the sense that appropriately controlling for those confounder(s) would have shifted the effect heterogeneity estimate to the null, or alternatively would have shifted its confidence interval to include the null. One can also consider shifting the estimate or confidence interval to an arbitrary non-null value. All of these E-values can be obtained using the R package EValue.ResultsWe illustrate applying the proposed E-value analogues to studies on: (i) effect heterogeneity by sex of the effect of educational attainment on dementia incidence and (ii) effect heterogeneity by age on the effect of obesity on all-cause mortality.ConclusionReporting these proposed E-values could help characterize the robustness of effect heterogeneity estimates to potential uncontrolled confounding.

PurposeSocial policies are important determinants of population health but may have varying effects on subgroups of people. Evaluating heterogeneous treatment effects (HTEs) of social policies is critical to determine how social policies will affect health inequities. Methods for evaluating HTEs are not standardized. Little is known about how often and by what methods HTEs are assessed in social policy and health research.MethodsA sample of 55 articles from 2019 on the health effects of social policies were evaluated for frequency of reporting HTEs; for what subgroupings HTEs were reported; frequency of a priori specification of intent to assess HTEs; and methods used for assessing HTEs.ResultsA total of 24 (44%) studies described some form of HTE assessment, including by age, gender, education, race/ethnicity, and/or geography. Among studies assessing HTEs, 63% specified HTE assessment a priori, and most (71%) used descriptive methods such as stratification; 21% used statistical tests (e.g., interaction terms in a regression); and no studies used data-driven algorithms.ConclusionsAlthough understanding HTEs could enhance policy and practice-based efforts to reduce inequities, it is not routine research practice. Increased evaluation of HTEs across relevant subgroups is needed.

Stepped wedge design is a popular research design that enables a rigorous evaluation of candidate interventions by using a staggered cluster randomization strategy. While analytical methods were developed for designing stepped wedge trials, the prior focus has been solely on testing for the average treatment effect. With a growing interest on formal evaluation of the heterogeneity of treatment effects across patient subpopulations, trial planning efforts need appropriate methods to accurately identify sample sizes or design configurations that can generate evidence for both the average treatment effect and variations in subgroup treatment effects. To fill in that important gap, this article derives novel variance formulas for confirmatory analyses of treatment effect heterogeneity, that are applicable to both cross‐sectional and closed‐cohort stepped wedge designs. We additionally point out that the same framework can be used for more efficient average treatment effect analyses via covariate adjustment, and allows the use of familiar power formulas for average treatment effect analyses to proceed. Our results further sheds light on optimal design allocations of clusters to maximize the weighted precision for assessing both the average and heterogeneous treatment effects. We apply the new methods to the Lumbar Imaging with Reporting of Epidemiology Trial, and carry out a simulation study to validate our new methods. [ABSTRACT FROM AUTHOR]

Background: Redlining has been associated with worse health outcomes and various environmental disparities, separately, but little is known of the interaction between these two factors, if any. We aimed to estimate whether living in a historically-redlined area modifies the effects of exposures to ambient PM2.5 and extreme heat on mortality by non-external causes. Methods: We merged 8,884,733 adult mortality records from thirteen state departments of public health with scanned and georeferenced Home Owners Loan Corporation (HOLC) maps from the University of Richmond, daily average PM2.5 from a sophisticated prediction model on a 1-km grid, and daily temperature and vapor pressure from the Daymet V4 1-km grid. A case-crossover approach was used to assess modification of the effects of ambient PM2.5 and extreme heat exposures by redlining and control for all fixed and slow-varying factors by design. Multiple moving averages of PM2.5 and duration-aware analyses of extreme heat were used to assess the most vulnerable time windows. Results: We found significant statistical interactions between living in a redlined area and exposures to both ambient PM2.5 and extreme heat. Individuals who lived in redlined areas had an interaction odds ratio for mortality of 1.0093 (95% confidence interval [CI]: 1.0084, 1.0101) for each 10 µg m−3 increase in same-day ambient PM2.5 compared to individuals who did not live in redlined areas. For extreme heat, the interaction odds ratio was 1.0218 (95% CI 1.0031, 1.0408). Conclusions: Living in areas that were historically-redlined in the 1930's increases the effects of exposures to both PM2.5 and extreme heat on mortality by non-external causes, suggesting that interventions to reduce environmental health disparities can be more effective by also considering the social context of an area and how to reduce disparities there. Further study is required to ascertain the specific pathways through which this effect modification operates and to develop interventions that can contribute to health equity for individuals living in these areas. [ABSTRACT FROM AUTHOR]

Background: Hyperuricemia has placed an immense burden on the global healthcare system. Studies have discovered a close correlation between serum uric acid (SUA) and insulin resistance (IR). The objective of this investigation is to examine the association between the triglyceride-glucose (TyG) index, a simple surrogate for IR, and the presence of hyperuricemia. Methods: Between 2017 and 2021, an epidemiologic study was conducted on Royal Thai Army (RTA) personnel aged 35–60 years, involving a total of 231,286 participants. In the study, hyperuricemia was defined as a SUA level of 7 mg/dL and 6 mg/dL among male and female participants, respectively. Using linear regression analysis and logistic regression analysis, the association between the TyG index and SUA was determined. Results: A positive relationship was demonstrated between the TyG index and the SUA. Overall, SUA increased by 0.32 per unit of TyG index growth (95% CI: 0.31–0.32). In comparison with the first quartile, employees in the fourth TyG quartile had a greater likelihood of having hyperuricemia [adjusted odds ratio (AOR): 2.45, 95% CI: 2.38–2.52]. Effect modification by obesity on the association between the TyG index and SUA was observed (P-interaction < 0.001). Among individuals with obesity, compared with the first TyG index quartile, the AOR for hyperuricemia was 2.15 (95% CI: 2.06–2.25) and 2.14 (95% CI: 1.81–2.53) for the fourth quartile of the TyG index for males and females, respectively. However, for nonobese personnel, in comparison to the top quartile of the TyG index, the AOR for hyperuricemia was 2.73 (95% CI:2.61–2.84) and 5.03 (95% CI: 4.03–6.29) for the fourth quartile of the TyG index for males and females, respectively. Personnel in the fourth TyG index quartile revealed that the prevalence of hyperuricemia reached 44.2%. Conclusion: A robust positive association between the TyG index and SUA was illustrated among active-duty RTA personnel. Obesity was identified as a modifier influencing this relationship. Furthermore, individuals in the fourth quarter of the TyG index, regardless of their obesity status, could be considered appropriate candidates for screening SUA levels. [ABSTRACT FROM AUTHOR]